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Understanding Orthodontic
Bone Screws
Agharsh Chandrasekaran, H.P. Naga Deepti
and Harshavardhan Kidiyoor
“Progress is impossible without change, and those who cannot change their minds
cannot change anything.”
—George Bernard Shaw
Abstract
1. Introduction
The goal of any orthodontic treatment is to achieve desired tooth movement with
the minimum number of undesirable side effects [1]. Strategies for anchorage control
have been a major factor in achieving successful orthodontic treatment since the
specialty began. With conventional orthodontics, it is almost impossible to achieve
absolute intraoral anchorage. Recently, the use of skeletal anchorage has grown in
popularity, especially in challenging situations [2].
The field of orthodontics has had a lot of landmarks in its evolution, but very few
can match the clinical impact made by micro-implants and the recently introduced
extra-radicular bone screws. Temporary anchorage devices have revolutionized the
orthodontic field with their concept of absolute anchorage and have proved to be an
adjunct in the hands of a clinician to gain control in handling complex malocclusions
and clinical challenges.
It aids in the conversion of borderline surgical cases to cases that can be handled
with bone screws in an equally effective way. The purpose of this review chapter is to
offer to the reader, an insight into the depths of orthodontic bone screws from cradle
to what has been explored till date, while touching upon integral aspects that might
prove to be of use in both an academic and a clinical sense [3].
2. History
Creekmore and Eklund (1983) used a small-sized vitallium bone screw to depress the
entire anterior maxillary dentition. The screw was inserted just below the anterior nasal
spine. Ten days after placement, a light elastic thread was tied from the head of the screw
to the archwire. The maxillary central incisors were intruded by about 6 mm. The bone
screw did not move during treatment and was not mobile at the time of removal [4].
Shapiro and Kokich (1988) described the possibility of using dental implants for
anchorage during orthodontic treatment. Melsen and co-workers (1998) introduced
the use of zygomatic ligatures as anchorage in partially edentulous patients. Under
local anesthesia, two holes were made in the superior portion of infrazygomatic crest.
A double-twisted 0.012″ stainless steel wire was ligated between the two holes and
inserted into the oral cavity. After surgery, nickel-titanium coil springs were attached
from the zygomatic ligatures to the anterior fixed appliance for intrusion and retrac-
tion of maxillary incisors [5].
Mindful of the fact that orthodontic bone screws have insertion points in areas
with greater quantities of cortical bone, the regular mini-implant has been revamped
with the following design features to form a bone screw (Figure 1) [2, 3]:
• A length of 10–14 mm that facilitates insertion in areas of high bone density with
adequate primary stability. Also, the increased length is owed to its placement
steered away from the roots at extra-alveolar sites.
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Understanding Orthodontic Bone Screws
DOI: http://dx.doi.org/10.5772/intechopen.100276
Figure 1.
Diagrammatic representation of orthodontic bone screw.
• A four-way rectangular hole that offers a lever arm for disimpacting canines.
• A double neck feature that permits better maintenance of oral hygiene and
additional attachments.
Bone screws inserted in extra-alveolar areas are made up of either stainless steel
or titanium alloys (Ti-6 AI-4 V). There has been a serious bone of contention over the
material of choice. Pure surgical stainless steel has gained more popularity in being
the preferred material of choice.
The reason for stainless steel being the popular material of choice is attributed to
the high placement torque that occurs when these screws are placed in areas of high
bone density. This demands the requisite of a high fracture resistance, and stainless
steel seems to be a befitting choice due to its high modulus of elasticity in comparison
with titanium alloy. However, both materials seem to be acceptable materials with a
comparable success rate [6].
A popular titanium alternative is the Peclab screw kit that was developed by
Almeida [7] that has shown promising results and is inclusive in terms of the arma-
mentarium that is required.
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Current Trends in Orthodontics
The bone thickness also seemed to vary with different divergence patterns.
Infrazygomatic crest region did not show any change with regard to the patient’s
vertical height. But the bone thickness at the buccal shelf region was found to be
higher in short-faced individuals as compared to long-faced individuals [10]. Also, in
comparison with the hyperdivergent counterparts, the buccal shelf has greater bone
width and lesser bone height in hypodivergent individuals [11].
6. Envelope of discrepancy
Figure 2.
Revised envelope of discrepency.
Figure 3.
Revised envelope of discrepency.
Figure 4.
Revised envelope of discrepency.
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Current Trends in Orthodontics
1. Borderline cases,
2. Camouflage treatment,
4. Anterior open bite treatment with molar intrusion (with or without extractions),
7. Extraction cases,
3. Psychological disorders,
The infrazygomatic crest is a crest of bone emanating from the buccal plate of
the alveolar process, lateral to the roots of the first and second maxillary molars. It
extends superiorly up to 2 cm to the zygomaticomaxillary suture and inferiorly into
the areas of first and second maxillary permanent molars. The sites of placement at
first or second molar have been much discussed and have been proposed by authors
Liou and Lin respectively. Comparisons of both sites have been summarized in
Table 1 [14].
Though both sites have been deemed fit, the IZC 7 site gains an upper hand in
terms of having a greater bone thickness over the buccal surface of the second molar.
Nevertheless, a CBCT evaluation of the area before placement is an important aspect
of treatment planning with these screws.
Liou [15] suggested orienting screws about 55–70° inferior to the horizontal plane
to achieve maximal buccal bone engagement. During placement, the point of initial
insertion is between the first and second molar, 2 mm above the mucogingival junc-
tion. The screw is directed first at the right angle to the occlusal plane and after a
couple of turns when the initial notch has been made in the bone, the direction of the
driver is altered by 55°–70° toward the tooth. This downward change aids in bypass-
ing the roots of the teeth and helps direct the screw to the infra-zygomatic area of the
maxilla (Figure 5). The bone screw is screwed until only the screw head is visible.
The need for pre-drilling, flap raising, or a mucosal vertical slit has been deemed
unnecessary.
LIOU-IZC 6 LIN-IZC 7
PLACEMENT: Anterior to the anatomic ridge and PLACEMENT: Distal to the anatomic ridge and buccal
buccal to the mesiobuccal root of the maxillary first to the mesiobuccal root of the maxillary second
permanent molar. permanent molar.
Small oral cavities are more convenient to place Large oral cavities and lip reflection are needed for
screws at this site. adequate access.
Less predictable as compared to seven sites due More predictable and greater retraction due to greater
to lesser bone thickness over mesiobuccal and amount of bone thickness over mesiobuccal and
distobuccal roots of 6. distobuccal roots of 7.
Table 1.
LIOU-LIN concept of IZC site: A comparison.
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Current Trends in Orthodontics
Figure 5.
Insertion of infrazygomatic crest screw.
Cases with the maxillary sinus extending low between the teeth are not ideal can-
didates for infrazygomatic crest screws. The thickness of the sinus floor is preferred
to be over 6 mm to ensure safe insertion. Small uncomplicated penetrations into the
sinus heal spontaneously [16]. The penetration into the maxillary sinus with IZC
screws was found to be rather high and double cortical engagement with sinus pen-
etration within 1 mm was recommended for adequate primary stability. Penetrations
above 3 mm led to thickening of the Scheniderian membrane and sinusitis eventually
leading to failure [17].
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Understanding Orthodontic Bone Screws
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To ensure greater precision, a number of guides [14] have been made available for
easy installation of IZC screws. They are as follows:
• Double film method with a transparent adhesive patch like comfort brace strips.
Mandibular buccal shelf area is located in the posterior part of the mandibular
body, buccal to the roots of the mandibular, and anterior to the oblique line of the
mandibular ramus. The area buccal to the distal root of the mandibular second molar,
between 4 and 8 mm from the cementoenamel junction, has been claimed to be the
best anatomical location for fixation. However, the region shows significant anatomic
variations and also possibly ethnic variations wherein some patients present with a
well-defined bony plateau and some with a straight bony profile. This could be better
evaluated with a CBCT and clinical examination [9].
While placing bone screws in the mandibular buccal shelf, the point of initial
insertion is between the first and the second molar, 2 mm below the mucogingival
junction. The screw is first directed at the right angle to the occlusal plane at this point
and then, the driving direction is altered by 60°–75° toward the tooth. This upward
change in direction helps to bypass the teeth roots and directs the screw to the buccal
shelf area of the mandible. Pre-drilling or vertical slit in the mucosa may be neces-
sary if the bone density is too thick. However, raising a flap is never required during
placement.
The intersection of the line of occlusion and the internal oblique ridgeline is the
inflection point (Figure 6). The second molar cannot move on the internal oblique
line, and the amount of possible movement depends on the distance of the original
position of the second molar to the inflection point. This varies from patient to patient.
A comprehensive evaluation of the buccal shelf area and the alveolar housing with the
help of a cone-beam computed tomogram seems pivotal to treatment planning [18].
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Current Trends in Orthodontics
Figure 6.
Limits of mandibular molar distalisation.
Figure 7.
Ramus Screw insertion.
Ramus screws were developed to overcome the difficulties that buccal shelf screws
posed during the dis-impaction of horizontally impacted lower molars. From the
standpoint of biomechanics, these screws are installed in the anterior ramus of the
mandible to offer a traction force that is more superior and posterior in direction.
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This coupled with simple yet efficient mechanics to upright the lower molars in
tandem with ramus screws has offered a brilliant treatment option in such cases.
The insertion site for a ramus screw (red arrows) is between external and internal
oblique ridges, about 5–8 mm superior to the occlusal plane (Figure 7).
A relatively long (14 mm) ramus screw is selected because of the need to penetrate
thick non keratinized mucosa, with an underlying layer of masticatory muscle. For
hygiene access, the ramus screws were screwed in until the head of the TAD was
~5 mm above the level of the soft tissue. The average bone engagement for a ramus
screw is ~3 mm [19].
Buccal shelf screws are employed for en masse retraction of the entire mandibular
dentition since the screws are placed at extra-alveolar sites.
Three critical factors exist for this system to be deemed statically determinate
when two screws are inserted into the buccal shelf areas for retraction:
• The axis of rotation was found close to the mandibular canine area.
• The counterclockwise rotation occurs since the line of force is occlusal to the
center of resistance and thus causing molar intrusion and incisor extrusion.
These movements offer favorable Class III correction presenting with
open bite.
When two screws are installed in the IZC area for retraction, similar effects were
found as in the buccal shelf region. With the retraction force from the coil spring to
the screw, retraction occurs along with vertical side effects, that is, molar intrusion
and incisor extrusion leading to rotation of the occlusal plane. The axis of rotation in
the maxillary arch lies between the premolars and this change is beneficial in Class II
cases with the open bite or where bite deepening is required.
10.5 How can the force system be varied to suit the needs of a particular case?
In order to overcome the side effects that are not suited for correction in
all cases, the force system can be modified to obtain different kinds of dental
movements:
Depending on the force vector and direction required in each case, the height of
the hook will help decide the type of tooth movement required along with torque and
vertical control.
Short hook: Anterior teeth have a tendency to rotate clockwise when retraction/
distalization force is applied by means of a force that passes below the Center of
resistance, which leads to torque loss and a vertical extrusion force on the incisors.
Medium hook: The force action line is passing over the anterior teeth’s center of
resistance, due to the middle positioning. When distalization force is applied to the
entire maxilla, with force parallel to the occlusal plane, anterior teeth are likely to
keep their initial inclination, minimizing vertical forces.
Long hook: The height of the hook is positioned mesial to the canine allows the
force action line to pass above the incisors’ center of resistance. The positioning
simply produces a counterclockwise anterior moment during retraction and simulta-
neous extrusion of the incisors. In the clinical scenario, it might be pointed out that
this may offer a possibility of injuring the oral mucosa of the patient.
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Understanding Orthodontic Bone Screws
DOI: http://dx.doi.org/10.5772/intechopen.100276
5. Mesialization of molars
4. Mesialization of molars
Table 2.
Clinical applications of extra-alveolar bone screws [2, 3, 4, 9].
In cases with vertical maxillary excess, in order to facilitate gingival smile correc-
tion while also balancing the clockwise rotation effect of the maxillary occlusal plane,
it was suggested that two mini-implants were to be installed between central and
lateral incisors apart from the IZC screws. This would help counter-effect the anterior
extrusion, resulting in the intrusion of the entire maxillary dentition and favoring
gingival smile correction (Table 2).
11. Conclusion
Author details
© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of
the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided
the original work is properly cited.
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Understanding Orthodontic Bone Screws
DOI: http://dx.doi.org/10.5772/intechopen.100276
References
[9] Park JH. Temporary Anchorage [17] Jia X, Chen X, Huang X. Influence of
Devices in Clinical Orthodontics. 1st ed. orthodontic mini-implant penetration of
Wiley Blackwell; 2020. p. 111 the maxillary sinus in the infrazygomatic
crest region. American Journal of
[10] Vargas EOA, Lopes de Lima R, Orthodontics and Dentofacial
Nojima LI. Mandibular buccal shelf and Orthopedics. 2018;153(5):656-661
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